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Steroids cause osteoporosis
  1. S Paget1
  1. 1Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
  1. Correspondence to
    Dr Paget;

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Excellent treatment options exist. So why don't we all prevent or treat it?

When doctors institute steroids for any illness and for any length of time, they take on a lifelong responsibility to that patient to both taper the drug as quickly as is possible and safe and prevent or treat the many well recognised steroid related side effects.1 This is particularly true when steroid treatment lasts for more than one month and certainly for many months or years. Rheumatologists have a particular accountability because of the 1% of the population who are receiving long term steroids, most have rheumatological disorders.2,3 Further, rheumatologists should have the best understanding of when the treatment course will be prolonged, the profound and negative physiological impact of steroids on bone, and the need to deal with this important issue in both men and women.4,5

A recent topic search for steroid-induced osteoporosis (SIO) yielded 79 000 articles since 1966 and 13 000 since l998, most of which focused on the pathogenesis, clinical manifestations, and treatment of SIO. Despite the saturation publication on this topic for years, doctors do not seem to take heed: the majority of bone loss is rapid; most of the 50% of patients with atraumatic fractures develop them in the first year; SIO is the third most common cause of osteoporosis; vertebral and hip fractures are associated with profound short and long term morbidity and mortality; and, most importantly, SIO is both avoidable and treatable.6,7 It is not a matter of whether clinically significant and quality of life altering bone loss will occur, but when. Similarly, it should not be a matter of whether treatment should be started, but how soon, and which therapeutic options should be instituted.

“Steroid-induced osteoporosis is both avoidable and treatable”

These facts make the results of the paper by Gudbjornsson et al in this journal all the more disturbing (see 32).8 Over a two year period, they carefully studied a well defined population of 26 664 patients in northeast Iceland to determine their corticosteroid use and clinical information about their medical disorders and possible steroid related side effects. Owing to the centralisation of drug distribution and medical care and the use of questionnaires, one can assume excellent capture of drug data and clinical data. If anything, their data probably underreport the breadth of steroid related bone disorders. One hundred and ninety one patients, or 0.7% of the population, were receiving chronic steroid treatment, defined conservatively as a time period of over three months of treatment. Although over a third of patients were receiving either calcium or vitamin D supplements, only 9% were taking bisphosphonates and 21% hormone replacement therapy. The take-home lesson from their excellent population and prevalence study in a well defined part of Iceland spells out a seemingly worldwide finding: a surprisingly large proportion of doctors who treat life or organ threatening inflammatory disorders do not appear automatically to connect the institution of steroids with the need for preventive, bone protecting treatment and monitoring for SIO.9

“Many doctors do not connect the institution of steroids with the need for preventive treatment against osteoporosis”

All doctors who write an initial prescription for a thiazide diuretic for hypertension would reflexively monitor and replace potassium and, similarly, those starting a chemotherapeutic agent for cancer would check a white blood cell count. We are now trying to decrease the use of antibiotics to avoid worsening bacterial resistance. Yet, the majority of steroid treated patients who should be given calcium, vitamin D3, and anti-resorptive agents, such as bisphosphonates, oestrogen replacement therapy, and calcitonin, are not. What can account for such a medical conundrum?

Mixed messages about the safety of oestrogen replacement therapy, the slowness of incorporation of medical advances into practice, and the newness of data about the effectiveness of bisphosphonates in preventing or reversing SIO all have a role.10,11 Also, despite a near educational blitz on this topic by pharmaceutical companies and doctors, it appears that doctors and patients are slow to learn in this setting of a bone disorder that may remain silent for many years after steroid institution. Clearly, also, many doctors who institute steroids believe that the course will be short. Then, when the regimen turns into a chronic phase, they either forget the drug's bone toxicity or are preoccupied by the disease that they are treating or the other more clinically apparent and disturbing steroid related side effects, such as infections, diabetes, or psychological and sleep problems.

Clearly, the answer is education and more rapid dissemination of information through journals and the internet. Neither the definition and measurement of bone loss with dual x ray absorptiometry nor the prophylaxis and treatment of SIO is perfect. However, the data strongly support their place in mainstream medicine in a manner similar to the measurement, treatment, and monitoring of hypertension, atherosclerosis, diabetes, asthma, and peptic ulcer disease. Reports like the one in this journal go a long way towards resetting the well meaning doctor's mind and putting SIO on their therapeutic radar screen. Hopefully, this group will look at this topic again in another two years and see whether their report, various excellent guidelines from national organisations, and the clinical use of new and exciting drugs, such as the bisphosphonates and the anabolic agent parathyroid hormone, will improve the focus and doctor's acceptance of, and action on, this important topic (table 1).6,12,13

Table 1

American College of Rheumatology recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis6

Excellent treatment options exist. So why don't we all prevent or treat it?


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